Reducing Restrictive Practices Bradley Brook

1. Reducing Restrictive Practices Bradley Brook

2. Bradley Brook Hx Factors • PICU within medium Secure Hospital • Changes to service MDT structure • High churn ward managers • Changes in commissioning profile • Circa ten fold increase in violence and RP 1stQtr 2017

3. Immediate Actions • Dig into clinical rationale • Refocus treatment and care pathway • Improved MDT communication • Review of risk management processes

4. Initial Results • Graduated reduction in violence and RP incidents • 2ndQtr 2018 to below baseline levels from 2015-2017 • Increased average length of stay in seclusion • Improved ward confidence in risk management

5. Current • We still have high long term use of seclusion • We want to see how we can reduce all RP further • We want to encourage best practice within unit • Focus on staff wellbeing, retention and development • Activity coordinator employed June 2018 • National Collaborating Centre for Mental Health • (Joint UCL and RCP) • Selected to join RRPP Oct 2018

6. Reducing Restrictive Practice Programme • By April 2020 1/3 reduction in restraint, seclusion and RT • Three principles: • Design the program in collaboration with experts and experts by experience • Provide tools and resources for selected wards to develop their own quality improvement plans • Support wards to carry out quality improvement through bimonthly learning days and dedicated Quality Improvement Coaches

7. Ward Initiatives • MDT Reflective Practice Group • 4 Steps to Safety + RAID • Handover folder • B6/7 Leadership Training • SUSG • CSP • Chill out room (Use of proactive rather than Reactive strategies) • Safewards • Engagement within Seclusion • Huddles / Barriers Change Checklist

11. Example • SU XX currently on Ward • Relapse of Psychosis co-morbid with PD • Aggressive behaviour displayed – staff hurt • Staff attitude default at ‘Seclude’ • RRP Approach = Verbal de-escalation • Seclude as last resort / all options explored

12. Occupational Therapy and Activity coordinator • OT and AC working together to maximise engagement time and shorten waiting time for groups and activities. • Introduction of full time OT (1 OT covering 2 wards until July 2018) • Introduction of full time activity coordinator (Brand new role to ward and part of RRP initiative) • Activity provision provided 7 days a week • Occupational Therapy focus on assessment, skills based work, 1:1 work, motivation • Activity coordinator focus on occupational deprivation, initial engagement and leisure based groups • Culture change- activity provision is everybody's responsibility

13. Creation of 7 day Ward Week Activity Timetable A typical group programme for a Bradley patient (excluding 1:1 focused intervention/OT and nursing 1:1s) • Working together AC and OT to create a varied and meaningful activities program tailored for the individual

14. Positive risk taking increases engagement and reduces risk OT men’s shed, yoga, gardening • Practical skills men shed- working with more risky materials wood, sandpaper, hammering, gluing, painting. Increased motivation, skills maintenance, meaningful engagement. • Yoga- initially deemed too risky due to floor work/positioning. Introduction of group to help physical health, relaxation and mental well-being. Patients reported feeling more relaxed/at ease- reduction in aggression • Gardening- introduction of tools/equipment. Focus on nurturing and utilising plants for food. Association of tools with nurturing and skills rather than violence. Therapeutic benefits of gardening in risk reduction. AC examples of risk taking • Photography group- Initially deemed to risky and staff reservation towards the equipment used, the risky of photographing other service users and breaching confidentially. • Darts-Reservations due to risk items combatted with suitable alternative. • Ping Pong- Reservation due to ligature risk • Oasis sculpture block an alternative to wood

16. AC Photography Groups

17. Occupational Therapy in seclusion • Enhanced care-plans working with those in seclusion • MDT discussion around items introduced into seclusion environment • New seclusion resources pack with activities/items all staff can use to engage with patient • OT 1:1 sessions in seclusion- cooking, origami, card games, soft ball games, colouring/craft work, listening to music. • Continuity of group work- running 1:1 adapted version of groups in seclusion. • Initiatives all working towards decreased time in seclusion and motivating individuals to want to engage in activities on ward • Meaningful engagement in sterile environment and reduction of occupational deprivation • Working together with AC to create a varied and meaningful activities programme tailored for the individual i.e. Christmas card making, baking, photography appreciation and exercise groups to name a few!

18. Positive meaningful engagement reduces risk

19. Total number of physical restraints, each month (Bradley Brook, Aug ‘17 – Feb ’19)

20. Developments/Ongoing OT/AC initiatives to reduce restrictive practice • Culture change- activity provision is everybody’s responsibility • To put into action service users request’s at a faster rate. Coproduction of activities with service users and structure of day • Occupational Therapy and activity coordinators working together to develop a training for ward staff to role out groups also- consistent engagement reduces risk. • Using safe wards getting to know you groups (If a staff member has a specific interest or skill we can use this for service users to get to know staff better and feel less of them and us. • Activity coordinators receiving clinical supervision from OT • New groups and 1:1 sessions such as relaxation/mindfulness and emotional regulation sessions to be held in new calm down room • Continue to offer groups that positive risk take • Reviewing/updating seclusion resources to increase engagement and reduce occupational deprivation in seclusion environment

21. Next Steps • Full Team Meetings Monthly (Inc QI Support Manager) • Attend Bi-monthly National Workshops – Shared Practice • Employ an Expert by Experience via SU Job Role • Implement this Quarters Target Areas- • ‘Chill Out Room’ • Intentional Rounding • Zoning • Service User De-Briefing

22. Chill Out Room • Blackboard Wall (Expression through written word) • Textures/Textiles – (Comfort) • Controlled/Mood Lighting (SU Researching currently) • Reading Corner – (BB SU’s suggested Magazine Subscriptions) • Discussed at Secure Services SUSG

24. Intentional Rounding • Intervention 5 of ‘4 Steps to Safety’ – 1st PDSA • Regular Interaction between patients and staff • Staff to promote Proactive engagement with SU’s so that their needs are understood and acted upon quickly to avoid escalation in V&A. • NIC ensures each staffs key SU’s have 3x IR interventions per day – documented on RIO. • Explain to SU’s what IR is and its purpose – To enhance communication between SU & Staff.

25. Zoning • Intervention 3 of ‘4 Steps to Safety’ • A ‘RAG’ rated system that quickly identifies needs and interventions to reduce overall risk to the SU. • SU’s Zoned in Red / Amber and Green – according to their current presentation. • To be discussed (and amended as needed) in all handovers/MDT discussions ect • A task focused activity – staff collectively decide when to move SU’s in Zones and interventions needed. (CSP’s)